By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Humana in North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Cometriq Covered by Humana in North Carolina

Cometriq (cabozantinib) requires prior authorization from Humana and must be dispensed through CenterWell Specialty Pharmacy or another in-network specialty pharmacy. Your oncologist needs to submit documentation proving progressive, metastatic medullary thyroid carcinoma with pathology reports, recent imaging, and confirmation that surgery isn't curative. If denied, you have 65 days to appeal internally, then can request external review through North Carolina's Smart NC program within 120 days. Start by having your prescriber contact CenterWell at Humana's specialty pharmacy portal to initiate the prior authorization process.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Basics
  6. Step-by-Step: Fastest Path to Approval
  7. Common Denial Reasons & Solutions
  8. Appeals Process in North Carolina
  9. When to Contact Smart NC
  10. FAQ

Plan Types & Coverage Implications

Humana offers several plan types in North Carolina, each with different coverage rules for Cometriq:

Medicare Advantage Plans: Most common Humana coverage in North Carolina. These plans require prior authorization for Cometriq and typically classify it as a Tier 5 specialty drug. You'll need to use in-network specialty pharmacies and follow Medicare Part D appeal timelines.

Medicare Part D: Standalone prescription drug coverage that may not include Cometriq on the standard formulary, requiring a formulary exception request. Humana's exception process allows 72 hours for standard decisions and 24 hours for expedited requests.

Commercial Plans: Employer-sponsored Humana plans vary significantly in their specialty drug coverage. Check your specific formulary through Humana's drug list lookup to confirm coverage requirements.

Formulary Status & Tier Placement

Cometriq typically appears on Humana formularies as a Tier 5 specialty medication, meaning higher cost-sharing and mandatory specialty pharmacy dispensing. The medication requires prior authorization regardless of tier placement.

Key Formulary Details:

  • Generic name: Cabozantinib (capsules only—not interchangeable with Cabometyx tablets)
  • Tier: Usually Tier 5 (specialty)
  • Quantity limit: 30-day supply maximum per fill
  • Step therapy: May require trial of vandetanib first, depending on your specific plan
Note: Always verify your specific plan's formulary at Humana's provider portal as coverage can vary between plan years and regions.

Prior Authorization Requirements

Humana requires comprehensive documentation to approve Cometriq for medullary thyroid carcinoma. Here's what your oncologist must submit:

Clinical Documentation Checklist

Requirement Details Source
Diagnosis confirmation Pathology report with medullary thyroid carcinoma Humana PA guidelines
ICD-10 code C73 (Malignant neoplasm of thyroid gland) Clinical documentation
Disease progression Recent imaging (CT, MRI, PET) showing metastatic disease Within 30-60 days
Surgical status Statement that disease is not amenable to curative surgery Oncologist or surgeon note
Patient age Must be 18 years or older Date of birth verification
Prior treatments History of previous therapies and outcomes Treatment records
Prescriber credentials Oncologist NPI and specialty certification Provider information

Medical Necessity Letter Requirements

Your oncologist's letter should include:

  • Confirmed MTC diagnosis with ICD-10 code C73
  • Clinical rationale for cabozantinib therapy
  • Proposed dosing (typically 140 mg daily per FDA labeling)
  • Statement confirming no contraindications
  • Prior treatment history and rationale for current choice

Specialty Pharmacy Network

Cometriq must be dispensed through Humana's specialty pharmacy network—retail pharmacies cannot fill this prescription for covered members.

Primary Options:

  • CenterWell Specialty Pharmacy: Humana's preferred partner for most specialty medications
  • Other in-network specialty pharmacies: Varies by plan and region

To initiate dispensing:

  1. Your prescriber contacts CenterWell Specialty Pharmacy
  2. CenterWell coordinates with your oncologist for prior authorization
  3. Once approved, medication ships directly to your home with clinical support
Important: Out-of-network specialty pharmacy fills are not covered except in limited emergency circumstances.

Cost-Share Basics

As a Tier 5 specialty drug, Cometriq typically involves:

  • Deductible: May apply before coverage begins
  • Coinsurance: Usually 25-33% of the medication cost for Medicare plans
  • Monthly maximums: Some plans cap specialty drug costs at $200-400 per month

Cost-Saving Resources:

This information is educational only and not financial advice. Verify your specific cost-sharing with Humana member services.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and oncologist What: Pathology report, recent imaging, surgical consultation notes, insurance card Timeline: Before PA submission

2. Complete Prior Authorization Form

Who: Prescriber or their staff What: Humana PA form via provider portal Timeline: Submit within 24-48 hours of gathering documents

3. Submit Medical Necessity Letter

Who: Oncologist What: Detailed letter with diagnosis, rationale, and treatment plan Timeline: Include with PA form submission

4. Coordinate with CenterWell

Who: Prescriber What: Contact specialty pharmacy to initiate prescription Timeline: Same day as PA submission

5. Track Authorization Status

Who: Patient or prescriber What: Monitor through Humana provider portal or member services Timeline: Check within 2-3 business days

6. Follow Up on Decision

Who: Patient and prescriber What: Receive approval or prepare appeal documentation Timeline: Humana responds within 30 days (standard) or 72 hours (expedited)

7. Appeal if Denied

Who: Patient with prescriber support What: Submit internal appeal within 65 days Timeline: Humana responds within 7 days for Part D appeals

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Incorrect formulation Specify Cometriq capsules, not Cabometyx tablets Updated prescription with correct drug name
Missing MTC diagnosis Submit pathology report confirming medullary thyroid carcinoma Pathology report with ICD-10 code C73
Insufficient disease progression Provide recent imaging showing metastatic disease CT, MRI, or PET scan within 60 days
Step therapy not met Document vandetanib trial or contraindication Prior treatment records or medical contraindication
Age requirement Confirm patient is 18 or older Date of birth verification

Appeals Process in North Carolina

If Humana denies your Cometriq prior authorization, North Carolina offers robust appeal rights:

Internal Appeals (First Step)

  • Timeline: Submit within 65 days of denial
  • Humana response: 7 days for Part D, 30 days for Medicare Advantage
  • Required: Humana appeal form with additional medical evidence

External Review through Smart NC

North Carolina's external review program provides an independent assessment when internal appeals fail.

Key Benefits:

  • Independent review: Assigned to rotating Independent Review Organizations (IROs)
  • Fast decisions: 45 days standard, 72 hours expedited
  • Binding results: If approved, Humana must provide coverage within 3 business days
  • Free advocacy: Smart NC staff help with paperwork and process

Eligibility Requirements:

  • Exhausted Humana's internal appeals (or qualify for expedited review)
  • State-regulated plan (most individual and small group plans qualify)
  • Denial based on medical necessity or experimental treatment determination

When to Contact Smart NC

Contact Smart NC at 1-855-408-1212 if:

  • Humana's internal appeal is denied
  • You need urgent medication access (expedited external review)
  • You're unsure about appeal procedures or deadlines
  • You need help gathering medical evidence for your case
From our advocates: "We've seen several North Carolina patients successfully overturn Humana denials for expensive cancer medications through Smart NC's external review process. The key is submitting comprehensive medical records and clearly demonstrating that the denied treatment follows FDA-approved indications. While oncology cases historically have about a 31% overturn rate, strong documentation significantly improves your chances."

Cost and Financial Assistance

Without insurance coverage, Cometriq costs approximately $18,938 for a 112-capsule supply (one month at 140 mg daily). Financial assistance options include:

  • Manufacturer support programs: Check Cometriq's patient assistance page for eligibility
  • CenterWell patient support: Specialty pharmacy coordinators help navigate assistance programs
  • Foundation grants: Organizations like CancerCare and Patient Advocate Foundation offer emergency assistance

When navigating coverage challenges, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with payer requirements, helping patients access critical medications like Cometriq more efficiently.

FAQ

Q: How long does Humana's prior authorization process take in North Carolina? A: Standard prior authorizations receive decisions within 30 days for Medicare Advantage plans and 72 hours for Part D formulary exceptions. Expedited requests are decided within 72 hours (Medicare Advantage) or 24 hours (Part D).

Q: What if Cometriq isn't on my Humana formulary? A: You can request a formulary exception with your prescriber's supporting statement. Humana's exception process allows 72 hours for standard decisions.

Q: Can I use a retail pharmacy for Cometriq? A: No, Cometriq must be dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy. Retail pharmacies cannot fill covered prescriptions for this medication.

Q: What's the difference between Cometriq and Cabometyx? A: While both contain cabozantinib, Cometriq capsules and Cabometyx tablets are not interchangeable per FDA labeling. Ensure your prescription specifically requests Cometriq capsules for medullary thyroid carcinoma.

Q: How do I request an expedited appeal in North Carolina? A: Contact Humana member services to request expedited processing if delays could jeopardize your health. For external review, contact Smart NC at 1-855-408-1212 to request expedited processing (72-hour decision timeline).

Q: What happens if Smart NC overturns Humana's denial? A: The decision is binding—Humana must provide coverage within 3 business days of Smart NC's favorable decision.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and is not medical advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult your healthcare provider for medical decisions and verify current policy details with Humana. For personalized help with complex coverage challenges, Counterforce Health offers specialized support in navigating prior authorization and appeals processes.

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